ACC Form

ACC 45 Form- Personal details

Please complete patient form as below.
Patient Name

First NameLast Name
Date of Birth

DayMonthYear
Address

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Gender
Home Phone

Area CodePhone Number
Work Phone

Area CodePhone Number
Cell Phone

Area CodePhone Number
Patient E-Mail
example@gmail.com
What is your ethnic background? This information is collected for statistical reasons only.
Accident & Employment Details

You can provide the information as best as you can to the following questions on this form.
When did the accident happen?

DayMonthYear
Date
At what time?

:HourMinutesAM/PM Option
Accident Scene (e.g home, place of work, road)
Accident Location (e.g Auckland)
Did the accident happen in NZ?
What were you doing? - what happened - how was the injury caused?(e.g lifting box, strained lower back)
Did the accident involve a moving vehicle on a public road?
If sporting injury name sport: (e.g soccer)
Occupation
Please tick those that apply:
What type of work do you do?
Did the injury happen at work?
If Yes, Employer Name:
Employer Address:
Patient Authorisation and Declaration

I have read and understood the important Patient Information and Patient Declaration
I have provided the information on this form as best as I can and declare that this information is true and correct as I understood so far for claiming ACC. And I agree that I am giving permission to my provider to claim ACC based on the information as stated as above. If ACC declines the claim, I agree that I am liable to pay the full amount of treatment cost on the visits as I have visited.
Client Signature

By signing you agree to the conditions stated above
Todays Date

DayMonthYear
Should be Empty:

ACC 45 Form- Personal details

Accident & Employment Details

Patient Authorisation and Declaration